Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

1. By- Isha Thapa Magar
Nursing Instructor

3. Introduction
Bipolar disorder is mood disorder
characterized by mood swings from manic
episodes to depressive episodes in the same
patient at different times and usually
accomplished by abnormalities in thinking,
perception and behavior arising out of mood
disturbances.

4. It was formerly known as "Manic Depressive
Psychosis" (MDP).
 During manic phases, client are euphoric,
grandiose, energetic and sleepless. They have
poor judgment and rapid thoughts, actions
and speech.
 During depressed phases, mood behavior and
thoughts are the same as persons diagnosed
with major depression.

5. Bipolar mood disorder has an earlier age of
onset i.e. third decade and an average
episode last for 3-4 months while a
depressive episode lasts from 4-6 months.
With rapid institution of treatment, the major
symptoms of mania are controlled within 2
weeks and of depression within 6-8 weeks.

6. In case of depressive episodes;
 nearly 40% of depressives with episodic
course improve in 3 months,
 60% in 6 months and 80% improve within a
period of one year,
 15-20% of patients develop chronic course of
illness, which may last for two or more years.

7. Etiology
The etiology of mood disorders is not known
currently,
A. Biological Theories
1. Genetic Hypothesis
• The life-time risk for the first degree relatives of
bipolar mood disorder patients is 25%, and of
recurrent depressive disorder patients is 20%
• The life-time risk for the children of one parent
with bipolar mood disorder is 27% and of both
parents with bipolar mood disorder is 74%.

8. • The concordance rate in bipolar disorders for
monozygotic twins is 65% and for dizygotic
twins is 20%.
2. Biochemical Theories
• An abnormality in norepinephrine, dopamine,
serotonin, Acetylcholine and GABA are
involved in bipolar mood disorders.
• The side effects of antidepressants and mood
stabilizers also cause bipolar mood disorders.

9. 3. Neuroendocrine Theories
• Endocrine function is often disturbed in
depression such as hypothyroidism, Crushing's
disease, and Addison's disease.
4. Sleep studies
• Sleep abnormalities are common in mood
disorders e.g. decreased need for sleep in
mania; insomnia and frequent awakening in
depression.

10. • In depression, the commonly observed
abnormalities include decreased REM latency
( i.e. the time between falling asleep and the
first REM period is decreased), increased
duration of the first REM period, and delayed
sleep onset.

12. 5. Brain Imaging
• In mood disorders, brain imaging studies;
findings include ventricular dilatation, white
matter hyper-intensities, and changes in the
blood flow and metabolism in several parts of
brain (such as prefrontal cortex, anterior
cingulated cortex, and caudate).

13. B. Psychosocial Theories
1. Psychoanalytic Theories
• In depression, loss of a libidinal object,
introjections of the lost object, fixation in the
oral sadistic phase of development, and
intense craving for narcissism or self-love are
some of the postulates of different
psychodynamic theories.
• Mania represents a reaction formation to
depression according to the psychodynamic
theory.

14. 2. Stress
• Increased number of stressful life events
before the onset or relapse has a formative
rather than a precipitating effect in depression
though they can serve a precipitant in mania.
• Increased stressors in the early period of
development are probably more important in
depression.

15. 3. Cognitive and Behavioral Theories
• The mechanisms of causation of depression,
according to these theories, include
- depressive negative cognition,
- learned helplessness and
- anger directed inwards.

16. Classification of Bipolar Disorders
1. Bipolar I Disorder
2. Bipoalar II Disorder
3. Cyclothymia
4. Bipolar Disorder Not otherwise Specific (BP-
NOS)

17. 1. Bipolar I Disorder
• Bipolar I disorder is characterized by at least
one manic episodes or mixed episodes and
one or more major depressive episodes.
• These episodes last for at least one week but
may continue for months.
• Between episodes, there may be periods of
normal functioning.

18. • Bipolar I disorder is the most severe form of
the illness.
• The manic symptoms are sometimes so severe
that the person may require immediate
hospital admission.

19. 2. Bipolar II Disorder
• Bipolar II Disorder is characterized by one or
more major depressive episodes with at least
one hypomanic episode(Not requiring
hospitalization).
• Between episodes, there may be periods of
normal functioning.
• Bipolar II disorder is believed to occur more
frequently in women than in men.

20. 3. Cyclothymic Disorder
• Cyclothymic Disorder refers to a persistent
instability in mood between mild depression
and mild elation lasting more than 2 years.
• Milder form of bipolar disorder the periods of
both mild depressive and hypomanic
symptoms are shorter, less severe and do not
occur with regularity.

21. 4. Bipolar Disorder Not otherwise
Specific (BP-NOS)
• In this, symptom does exist but does not meet
the criteria of either Bipolar disorder I or II or
cyclothymia.
• The symptoms are out of the range of person
normal behavior.

22. Clinical Features
A. Depressive episodes
• Constantly feeling sad or worthless
• Sleeping too much or too little
• Feeling tired and having little energy
• Appetite and weight changes
• Problems focusing
• Thoughts of suicide

23. B. Manic episodes
• Increase in energy level
• Less need for sleep
• Easily distracted
• Nonstop talking
• Increased self confidence
• Focused on getting things done, but does not
accomplish much
• Involved in risky activities even though bad things
may happen

24. C. A current episode can be;
• Hypomanic
• Manic without psychotic symptoms
• Manic with psychotic symptoms
• Mild or moderate depression
• Severe depression without psychotic
symptoms
• Severe depression psychotic symptoms
• Mixed

25. Diagnosis
History Taking
Mental Status Examination
Diagnostic Criteria of Diagnostic and
Statistical Manual of Mental Disorders (DSM)
For bipolar disorder are:

26. 1. Bipolar I Disorder
• Bipolar disorder is defined by manic or mixed
episodes that last at least seven days, or by
manic symptoms that are so severe that the
person needs immediate hospital care.
• Usually, depressive episodes occur as well,
typically lasting at least 2 weeks.

27. 2. Bipolar II Disorder defined by a pattern of
depressive episodes and hypomanic
episodes, but no full-blown manic or mixed
episodes.
3. Bipolar Disorder Not Otherwise Specified
(BP-NOS) diagnosed when symptoms of the
illness exist but do not meet diagnostic
criteria for either bipolar I or II. However, the
symptoms are clearly out of the person’s
normal range of behavior.

28. 4. Cyclothymic Disorder
• It is a mild form of bipolar disorder.
• People with cyclothymia have episodes of
hypomania as well as mild depression for at
least 2 years and the symptoms do not meet
the diagnostic requirements for any other
type of bipolar disorder.

29. Treatment
A. Mood stabilizers (Lithium)
• Mood stabilizers are usually the first choice to
treat bipolar disorder. Lithium also known as is
an effective mood stabilizer for treating both
manic and depressive episodes.

30. B. Other mood stabilizers
1. Sodium valproate
– For acute treatment of mania and prevention of
bipolar mood disorder.
– Particularly useful in those patients who are
refractory to lithium.
– The dose range is usually 1000-3000mg/day (the
therapeutic blood levels are 50-125 mg/ml).
– It has a faster onset of action than lithium,
therefore, it can be used in acute treatment of
mania effectively.

31. 2. Carbamazepine
– For acute treatment of mania and prevention of
bipolar mood disorder.
– Particularly useful in those patients who are
refractory to lithium and valproate.
– Particularly effective when EEG is abnormal
(although this is not necessary for the use of
carbamazepine).
– The dose range of carbamazepine is 600-1600
mg/day ( the therapeutic blood levels are 4-12
mg/ml).

32. 3. Lamotrigine
– Lamotrigine si particularly effective for bipolar
depression and is recommended by several
guidelines.
4. T3 and T4 as adjuncts for the treatment of
rapid cycling mood disorder and resistant
depression.

33. B. Atypical antipsychotics drugs such as
risperidone, olanzapine, quetiapine are
sometimes used to treat symptoms of bipolar
disorder. Often, these medications are taken
with other medications, such as
antidepressants.

34. C. Antidepressants such as Fluoxetine ,
paroxetine, sertraline, and bupropion; are
sometimes used to treat symptoms of
depression in bipolar disorder.

35. D. Psychotherapy
Cognitive behavioral therapy (CBT), which helps
people with bipolar disorder learn to change
harmful or negative thought patterns and
behaviors.
 Family-focused therapy, which involves family
members. It helps enhance family coping
strategies, such as recognizing new episodes early
and helping their loved one. This therapy also
improves communication among family
members, as well as problem-solving.

36. Interpersonal and social rhythm therapy, which
helps people with bipolar disorder improve their
relationships with others and manage their daily
routines. Regular daily routines and sleep
schedules may help protect against manic
episodes
 Psychoeducation; which teaches people with
bipolar disorder about the illness and its
treatment. Psychoeducation can help to
recognize signs of an impending mood swing so
they can seek treatment early, before a full-blown
episode occurs. It may also be helpful for family
members and caregivers.

37. E. Electroconvulsive Therapy (ECT)
• Electroconvulsive therapy (ECT) may be useful
for patient with severe bipolar disorder who
have not been able to recover with other
treatments.

38. Nursing Management
Nursing Diagnosis
• Potential risk for injury related to extreme
hyperactivity evidenced by increased
agitation, and lack of control over purposeless
and potentially injurious movement.
• Potential risk for violence: self-directed or
other directed related to manic excitement,
delusional thinking, hallucinations.

39. • Imbalanced nutrition: less than body
requirement related to refusal or inability to
sit still long enough to eat evidenced by loss of
weight.
• Disturbed thought processes related to
biochemical alterations in the brain evidenced
by delusions of grandeur and persecution.

40. • Disturbed sensory perception related to
biochemical alterations in the brain, possible
sleep deprivation, evidenced by auditory and
visual hallucinations.
• Impaired social interaction related to ego centric
and narcissistic behavior evidenced by inability to
develop satisfying relationships and manipulation
of others for own desires.
• Disturbed sleep pattern related to excessive
hyperactivity and agitation evidenced by difficulty
falling asleep and sleeping only short periods.